Wednesday, 5 February 2014

Rashtriya Bal Swasthya Karyakram (RBSK)

Rashtriya Bal Swasthya Karyakram is a new initiative aimed at screening over 27 Crore children from 0 to 18 years for 4 Ds -Defects at birth, Diseases, De­ficiencies and Development Delays including Disabilities. Children diagnosed with illnesses shall receive follow up including surgeries at tertiary level, free-of-cost under NRHM.

The task is gigantic but quite possible, through the systematic approach that RBSK envisages. Implemented in right earnest, it would yield rich dividends in protecting and promoting the health of our children. I sincerely hope that the States would accord utmost priority to it and thereby improve both survival and development of children.

NRHM exemplifi­es a strong partnership between Central and State Governments and together we must ensure that flexibility to funding under the Mission is well utilized for prioritizing high impact health interventions. RBSK also signals a leap forward in the direction of universal health care with precedence accorded to those segments of population who need it ­most of all.
I am confident that RBSK together with several other reproductive and child health initiatives under NRHM would bring long term health benefi­ts to women and children.
Ghulam Nabi Azad
Union Minister of Health & Family Welfare

In a vast country like India, the need for ensuring a healthy and dynamic future for a large populace and creating a developed society, agile and able to compete with the rest of the world, is of paramount importance. The dream of such a healthy and developed society can be achieved through concerted efforts and initiatives undertaken in a systematic manner at all levels. Equitable child health, care and early detection and treatment can be the most pragmatic initiative, or rather solution, at this juncture!
The ‘Child Health Screening and Early Intervention Services’ Programme under National Rural Health Mission initiated by the Ministry of Health and Family Welfare, therefore, aims at early detection and management of the 4Ds prevalent in children. These are Defects at Birth, Diseases in Children, De­ficiency conditions and Developmental Delays including Disabilities.
Health screening of children is a known intervention under the School Health Programme. It is now being expanded to cover all children from birth to 18 years of age. The Programme has been initiated as signi­ficant progress has already been made in reducing child mortality under the National Rural Health Mission. However, further gains can be achieved by early detection and management of conditions in all age groups.
Out of every 100 babies born in this country annually, 6 to 7 have a birth defect. In Indian context, this would translate to 1.7 million birth defects annually and would account for 9.6 per cent of all newborn deaths. Various nutritional de­ficiencies are affecting the preschool children range from 4 percent to 70 percent. Developmental delays are common in early childhood affecting at least 10 percent of the children. These delays, if not intervened timely, may lead to permanent disabilities with regard to cognition, hearing and vision.
There are also groups of diseases which are very common in children e.g., dental caries, otitis media, rheumatic heart disease and reactive airways diseases which can be cured if detected early. It is understood that early intervention and management can prevent these conditions to progress into more severe and debilitating forms, thereby reducing hospitalisation and resulting in improved school attendance.
The ‘Child Health Screening and Early Intervention Services’ will also translate into economic benefi­ts in the long run. Timely intervention would not only halt the condition to deteriorate but would also reduce the out-of-pocket (OOP) expenditure of the poor and the marginalised population in the country. Additionally, the Child Health Screening and Early Intervention Services will also provide country-wide epidemiological data on the 4 Ds. Such a data is expected to hold relevance for future planning of area speci­fic services.
Target Group
The services aim to cover all children of 0-6 years of age group in rural areas and urban slums, in addition to older children up to 18 years of age enrolled in classes 1st to 12th in Government and Government-aided schools. It is expected that these services will reach and benefi­t about 27 Crore children in a phased manner.
 Magnitude of Birth Defects, Deficiencies, Diseases, Developmental Delays and Disabilities in Children
Defects at Birth
With a large birth cohort of almost 26 million per year, India would account for the largest share of birth defects in the world. This would translate to an estimated 1.7 million babies born with birth defects annually. In the study conducted by National Neonatology Forum, congenital malformations were the second commonest cause (9.9%) of mortality among stillbirths and the fourth commonest cause (9.6%) of neonatal mortality and that accounted for 4 per cent of under-fi­ve mortality.
Evidence suggests that almost half of children under age ­five years (48%) are chronically malnourished. In numbers it would mean that more than 47 million children under ­five years are stunted, 43 percent of children under five years are underweight for their age and about 20 percent of children younger than ­five years of age are wasted. Over 6 percent of children less than fi­ve years of age suffer from Severe Acute Malnutrition (SAM). However, recent survey conducted in 100 worst affected districts showed SAM prevalence of 3 percent in children less than ­five years of age. Anaemia prevalence has been reported as high as 70 percent amongst under ­five children largely due to iron de­ficiency. The situation has virtually remained unchanged over the past decade. During pre-school years, children continue to suffer from adverse effects of anaemia, malnutrition and developmental disabilities, which ultimately also impact their performance in the school.
As reported in different surveys, the prevalence of dental caries varies between 50-60 percent among Indian school children. Rheumatic heart disease is reported at 1.5 per thousand among school children in the age group of 5-9 years and 0.13 to 1.1 per thousand among 10-14 years. The median prevalence of reactive air way disease including asthma among children is reported to be 4.75 percent.
Developmental Delays and Disabilities
Globally, 200 million children do not reach their developmental potential in the fi­rst ­five years because of poverty, poor health, nutrition and lack of early stimulation. The prevalence of early childhood stunting and the number of people living in absolute poverty could be used as proxy indicators of poor development in under ­five children.
Health Conditions Identified for Screening
Child Health Screening and Early Intervention Services under NRHM envisage to cover 30 identi­fied health conditions for early detection and free treatment and management. Based on the high prevalence of diseases like hypothyroidism, sickle cell anaemia and beta thalassemia in certain geographical pockets of some States/UTs, and availability of testing and specialized support facilities, these States and UTs may incorporate them as part of this initiative.
Implementation Mechanisms
The Operational Guidelines outline the following mechanism to reach all the target groups of children for health screening
For new born Facility-based newborn screening at public health facilities, by existing health manpower & Community based newborn screening at home through ASHAs for newborn till 6 weeks of age during home visitation.
For children 6 weeks to 6 years   Anganwadi Center based screening by the dedicated Mobile Health Teams
For children 6 years to 18 years Government and Government aided school based screening by dedicated Mobile Health Teams.
Facility based newborn screening  This includes screening of birth defects in institutional deliveries at public health facilities, especially at the designated delivery points by ANMs, Medical Officers/ Gynaecologists. Existing health service providers at all designated delivery points will be trained to detect, register report and refer birth defects to the District Early Intervention Centers in District Hospitals.
Community Based Newborn Screening (age 0-6 weeks) for Birth Defect
Accredited Social Health Activists (ASHAs) during home visits for newborn care will use the opportunity to screen the babies born at home and the institutions till six weeks of age. ASHAs will be trained with simple tools for detecting gross birth defects. Further ASHAs will mobilise caregivers of children to attend the local Anganwadi Centers for screening by the dedicated Mobile Health Team.
In order to ensure improved and enhanced outcome of the screening programme by Mobile Health Teams, ASHAs would particularly mobilise the children with low birth weight, underweight and children from households known to have any chronic illness (e.g., tuberculosis, HIV,haemoglobinopathy etc.). Line lists maintained by the ANMs and AWWs would also be used to mobilise children.
Screening of Children Aged 6 Weeks till 6 Years Attending Anganwadi Centers
Children in the age groups six weeks to six years of age will be examined in the Anganwadi Centers by the dedicated Mobile Health Teams.
Screening of Children Enrolled in Government and Government aided schools
For children in the age groups 6 to 18 years, who will be screened in Government and Government -aided schools, the Block will be the hub of activity for the programme. At least three dedicated Mobile Health Teams in each Block will be engaged to conduct screening of children. Villages within the jurisdiction of the Block would be distributed amongst the mobile health teams. The number of teams may vary depending on the number of Anganwadi Centers, difficult-to-reach areas and children enrolled in the schools. The screening of children in the Anganwadi Centers would be conducted at least twice a year and at least once a year for school children to begin with.
There is also a provision for engaging a Block Programme Manager for providing logistic support and for monitoring the entire health screening process. The Block Programme Manager is also expected to ensure referral support and manage compilation of the data. The Block teams will work under the overall guidance and supervision of the CHC Medical Officer. The Block Programme Manager will chalk out a detailed screening plan for all the three teams in consultation with schools, Anganwadi Centers and CHC Medical Officer.
District Early Intervention Center (DEIC)
An Early Intervention Center will be established at the District Hospital. The purpose of Early Intervention Center is to provide referral support to children detected with health conditions during health screening. A team consisting of Paediatrician, Medical officer, Staff Nurses, Paramedics will be engaged to provide services. There is also a provision for engaging a manager who would carry out mapping of tertiary care facilities in Government institutions for ensuring adequate referral support. The funds will be provided under NRHM for management at the tertiary level at the rates fi­xed by the State Governments in consultation with the Ministry of Health and Family Welfare.
Children and students presumptively diagnosed to have a disease/ defi­ciency/disability/ defect and who require confi­rmatory tests or further examination will be referred to the designated tertiary level public sector health facilities through the DEICs.
The DEIC would promptly respond to and manage all issues related to developmental delays, hearing defects, vision impairment, neuro-motor disorders, speech and language delay, autism and cognitive impairment. Beside this, the team at DEICs will also be involved in newborn screening at the District level. This Center would have the basic facilities to conduct tests for hearing, vision, neurological tests and behavioural assessment.
The States/UTs would conduct mapping to identify public health institutions through collaborative partners for provision of specialized tests and services. Private sector partnership/ NGOs providing specialised services can also be explored in case services at public health institutions providing tertiary care are not available. Accredited health institutions will be reimbursed for the specialised service provided as per the agreed cost of tests or treatment packages.
 Training and Institutional Collaboration
Training of the personnel involved in Child Health Screening and Early Intervention Services is an essential component of the programme as it would be instrumental in imparting necessary information and skills required for child health screening and enhancing the performance of all the personnel involved in the health screening process at various levels.
A ‘cascading training approach’ would be adopted in order to ensure free ‑flow of skills and knowledge at all levels and to maximize skill distribution. Standardized training modules/tools would be developed in partnership with technical support agencies and collaborative Centers as their technical knowledge and expertise will contribute to making the training process all comprehensive.
Reporting and Monitoring
A Nodal Office at the State, District and Block level will be identifi­ed for programme monitoring. The Block will be the hub of activity for all Child Health Screening and Early Intervention Services activities. The Block Programme Manager will assist the CHC Medical Officer in programme supervision and monitoring.
The ‘Child Health Screening Card’ is to be fi­lled up by the Block Health Teams for every child screened during the visit. The health care providers at all delivery points will screen the newborns and ­fill the same card, if referral is required. These children should be issued unique identi­fication number from the Mother and Child Tracking System (MCTS). The birth defects detected by ASHAs during home visits are to be referred to DH/ DEIC for further management. All children detected should be referred to the District Early Intervention Center for further management at the District or identi­fied tertiary level health institution.
Roll-Out Steps for Child Health Screening and Early Intervention Services
·      Identi­fication of State Nodal Persons for the Child Health Screening and Early Intervention Services.
·      Dissemination of ‘Operational Guidelines’ to all Districts.
·      Estimation of the State/ District magnitude of various diseases, defects, de­ficiencies, disabilities as per available national estimates.
·      State level orientation meeting.
·      Recruitment of District Nodal Persons.
·      Estimation of the total requirement of dedicated Mobile Health Teams & recruitment of the Mobile Health Teams.
·      Mapping of facilities/institutions (public and private for treatment of specifi­c health conditions).
·      Establishment of DEIC at the District Hospital.
·      Procurement of equipment for the Block Mobile Team and District Hospital (as per the list provided in the ‘Operational Guidelines’).
·      Translation of tools, training packages, printing of formats, training material.
·      Training of Master Trainers.
·      Block micro-plan for school and community visits monthly outreach plan based on the mapping of educational institutions and Anganwadis and enrollment in them.
·      The schedule of visits of the Block Mobile Teams should be communicated to the school, Anganwadi Centers, ASHAs, relevant authorities, students, parents and Local Government well in advance so that required preparations can be made.
·      Anganwadi Centers and school authorities should arrange for prior communication with parents and motivate them to participate in the process.

You May Also Like


Popular Posts